| Pdc Provo Llc | |
|
2520 N Univ Ave Suite 101 Provo UT 84604 | |
| (801) 426-6255 | |
| (801) 224-2966 |
| Full Name | Pdc Provo Llc |
|---|---|
| Speciality | Dentist |
| Location | 2520 N Univ Ave, Provo, Utah |
| Authorized Official Name and Position | Amber Johnson (OFFICE MANAGER) |
| Authorized Official Contact | 8014266255 |
| Accepts Medicare Insurance | This clinic does not participate in Medicare Program. |
| Mailing Address | Practice Location Address |
|---|---|
| Pdc Provo Llc 2520 N Univ Ave Suite 101 Provo UT 84604 Ph: (801) 426-6255 | Pdc Provo Llc 2520 N Univ Ave Suite 101 Provo UT 84604 Ph: (801) 426-6255 |
| NPI Number | 1396893012 |
|---|---|
| Provider Enumeration Date | 01/08/2007 |
| Last Update Date | 01/04/2013 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1396893012 | NPI | - | NPPES |
| 529113131001 | Medicaid | UT |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 122300000X | Dentist | 6026130 (Utah) | Primary |
| 1223G0001X | Dentist - General Practice | 3192 (Utah) | Secondary |
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